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Health |/assessment |/(Chapter |/3) |/Collecting
|/Objective |/data: |/Physical |/examination
|/JERSEY |/COLLEGE |/questions |/with |/answers
To |/become |/proficient |/with |/physical |/assessment |/skills, |/the |/nurse |/must |/have |/basic |/knowledge |/in |/ 3 |/areas: |/- |/CORRECT |/ANSWERS |/โโ- types |/and |/operation |/of |/equipment |/needed |/for |/the |/particular |/examination |/(e.g., |/penlight, |/sphygmomanometer, |/otoscope, |/tuning |/fork, |/stethoscope) -preparation |/of |/the |/setting, |/oneself, |/and |/the |/client |/for |/the |/physical |/assessment -performance |/of |/the |/four |/assessment |/techniques: |/inspection, |/palpation, |/percussion, |/and |/auscultation Preparing |/the |/physical |/setting |/- |/CORRECT |/ANSWERS |/โโ-may |/take |/place |/in |/a |/variety |/of |/settings |/such |/as |/a |/hospital |/room, |/outpatient |/clinic, |/physician's |/office, |/school |/health |/office, |/employee |/health |/office, |/or |/a |/client's |/home. -important |/that |/the |/nurse |/strive |/to |/ensure |/that |/the |/examination |/setting |/meets |/conditions Conditions |/that |/needs |/to |/meet |/the |/following |/conditions: |/- |/CORRECT |/ANSWERS |/โโ-Comfortable, |/warm |/room |/temperature: |/provide |/a |/warm |/blanket, |/if |/the |/room |/temp |/cannot |/be |/adjusted
-private |/area |/free |/of |/interruptions |/from |/others: |/close |/the |/door |/or |/pull |/the |/curtains |/if |/possible -quiet |/area |/free |/of |/distractions: |/turn |/off |/the |/radio, |/TV, |/or |/other |/noisy |/equipment -adequate |/lighting: |/it |/is |/best |/to |/use |/sunlight |/(when |/available). |/However, |/good |/overhead, |/lighting |/is |/sufficient. |/A |/portable |/lamp |/is |/helpful |/for |/illuminating |/the |/skin |/and |/for |/viewing |/shadows |/or |/contours -firm |/exam |/table |/or |/bed |/at |/a |/height |/that |/prevents |/stooping: |/a |/roll- up |/stool |/may |/be |/useful |/when |/it |/is |/necessary |/for |/the |/examiner |/to |/sit |/for |/parts |/of |/the |/assessment -a |/bedside |/table/tray |/to |/hold |/the |/equipment |/needed |/for |/the |/exam Preparing |/onself |/- |/CORRECT |/ANSWERS |/โโ-as |/a |/beginning |/examiner, |/it |/is |/helpful |/to |/assess |/your |/own |/feelings |/and |/anxieties |/before |/examining |/the |/client -achieve |/self-confidence |/in |/performing |/a |/physical |/assessment |/by |/practicing |/the |/techniques |/on |/a |/classmate, |/friend, |/or |/relative. -preventing |/the |/transmission |/of |/infectious |/agents -wash |/hands |/prior |/to |/exam, |/immediately |/after |/accidental |/direct |/contact |/with |/blood |/or |/other |/body |/fluids, |/and |/after |/completing |/the |/physical |/exam |/or |/after |/removing |/gloves. -always |/wear |/gloves |/if |/there |/is |/chance |/that |/you |/will |/come |/in |/direct |/contact |/with |/blood |/or |/other |/body |/fluids
-approach |/the |/client |/from |/the |/right-hand |/side |/of |/the |/exam |/table |/or |/bed |/because |/most |/exam |/techniques |/are |/performed |/with |/the |/examiner's |/right |/hand |/(even |/if |/your |/left-handed) Physical |/examination |/techniques |/- |/CORRECT |/ANSWERS |/โโ- inspection, |/palpation, |/percussion |/and |/auscultation Examiners |/should |/ask |/themselves |/questions |/that |/will |/facilitate |/analysis |/of |/the |/data |/and |/determine |/areas |/for |/which |/more |/data |/may |/be |/needed: |/- |/CORRECT |/ANSWERS |/โโ-did |/i |/inspect, |/palpate, |/percuss, |/or |/auscultate |/any |/deviations |/from |/the |/normal |/findings? -if |/there |/is |/a |/deviation, |/is |/it |/a |/normal |/physical, |/gerontologic, |/or |/cultural |/finding; |/an |/abnormal |/adult |/finding; |/or |/an |/abnormal |/physical, |/gerontologic; |/or |/cultural |/finding? -based |/on |/my |/findings, |/do |/i |/need |/to |/ask |/the |/client |/more |/questions |/to |/validate |/or |/obtain |/more |/information |/about |/my |/inspection, |/palpation, |/percussion, |/or |/auscultation |/findings? -based |/on |/my |/observations |/and |/data, |/do |/i |/need |/to |/focus |/my |/physical |/assessment |/on |/other |/related |/body |/systems? -should |/i |/validate |/my |/inspection, |/palpation, |/percussion, |/or |/auscultation |/findings |/with |/my |/instructor |/or |/another |/practitioner? -should |/i |/refer |/the |/client |/and |/data |/findings |/to |/a |/primary |/care |/provider?
Inspection |/- |/CORRECT |/ANSWERS |/โโ-involves |/using |/the |/senses |/of |/vision, |/smell |/and |/hearing |/to |/observe |/and |/detect |/any |/normal |/or |/abnormal |/findings -used |/from |/the |/moment |/that |/you |/meet |/the |/client |/and |/continues |/throughout |/the |/examination -inspection |/precedes |/palpation, |/percussion, |/and |/auscultation |/because |/the |/latter |/techniques |/can |/potentially |/alter |/the |/appearance |/of |/what |/is |/being |/inspected using |/the |/following |/guidelines |/as |/you |/practice |/the |/technique |/of |/inspection: |/- |/CORRECT |/ANSWERS |/โโ-make |/sure |/the |/room |/is |/a |/comfortable |/temperature -use |/good |/lighting, |/preferably |/sunlight -look |/and |/observe |/before |/touching -completely |/expose |/the |/body |/part |/you |/are |/inspecting |/while |/draping |/the |/rest |/of |/the |/client |/as |/appropriate -note |/the |/following |/characteristics |/while |/inspecting |/the |/client: |/color, |/patterns, |/size, |/location, |/consistency, |/symmetry, |/movement, |/behavior, |/odors, |/or |/sounds -compare |/the |/appearance |/of |/symmetric |/body |/parts |/or |/both |/sides |/of |/any |/individual |/body |/part Palpation |/- |/CORRECT |/ANSWERS |/โโ-texture |/(rough/smooth) -temperature |/(warm/cold)
Light |/palpation |/- |/CORRECT |/ANSWERS |/โโ-place |/your |/dominant |/hand |/lightly |/on |/the |/surface |/of |/the |/structure -should |/be |/very |/little |/or |/no |/depression |/(less |/than |/ 1 |/cm) -feel |/the |/surface |/structure |/using |/a |/circular |/motion -this |/technique |/to |/feel |/for |/pulses, |/tenderness, |/surface |/skin |/texture, |/temperature, |/and |/moisture. Moderate |/palpation |/- |/CORRECT |/ANSWERS |/โโ-depress |/the |/skin |/surface |/1-2 |/cm |/(0.5-0.75 |/in) |/with |/your |/dominant |/hand, |/and |/use |/a |/circular |/motion |/to |/feel |/for |/easily |/palpable |/body |/organs |/and |/massess -note |/the |/size, |/consistency, |/and |/mobility |/of |/structures |/you |/palpate Deep |/palpation |/- |/CORRECT |/ANSWERS |/โโ-place |/your |/dominant |/hand |/on |/the |/skin |/surface |/and |/your |/nondominant |/hand |/on |/top |/of |/your |/dominant |/hand |/to |/apply |/pressure -should |/result |/in |/a |/surface |/depression |/between |/2.5-5 |/cm |/(1-2 |/in) -allows |/you |/to |/feel |/very |/deep |/organs |/or |/structures |/that |/are |/covered |/by |/thick |/muscle Bimanual |/palpation |/- |/CORRECT |/ANSWERS |/โโ-use |/ 2 |/hands, |/placing |/one |/on |/each |/side |/of |/the |/body |/part |/being |/palpated -use |/one |/hand |/to |/apply |/to |/apply |/pressure |/and |/the |/other |/hand |/to |/feel |/the |/structure
-note |/the |/size, |/shape, |/consistency, |/and |/mobility |/of |/the |/structures |/you |/palpate Percussion |/- |/CORRECT |/ANSWERS |/โโ-involves |/tapping |/body |/parts |/to |/produce |/sound |/waves -sound |/waves |/or |/vibrations |/enable |/the |/examiner |/to |/assess |/underlying |/structures Eliciting |/pain |/- |/CORRECT |/ANSWERS |/โโ-percussion |/helps |/detect |/inflamed |/underlying |/structures. -if |/an |/inflamed |/area |/is |/percussed, |/the |/client's |/physical |/response |/may |/indicate |/or |/the |/client |/will |/report |/that |/the |/area |/feels |/tender, |/sore, |/or |/painful Determining |/location, |/size, |/and |/shape |/- |/CORRECT |/ANSWERS |/โโ- percussion |/note |/changes |/between |/borders |/of |/an |/organ |/and |/its |/neighboring |/organ |/can |/elicit |/information |/about |/location, |/size, |/and |/shape Determining |/density |/- |/CORRECT |/ANSWERS |/โโ-percussion |/helps |/determine |/whether |/an |/underlying |/structure |/is |/filled |/with |/air |/or |/fluid |/or |/is |/a |/solid |/structure Detecting |/abnormal |/masses |/- |/CORRECT |/ANSWERS |/โโ-percussion |/can |/detect |/superficial |/abnormal |/structures |/or |/masses
Solid |/tissue |/produces... |/- |/CORRECT |/ANSWERS |/โโ-a |/soft |/tone, |/fluid |/produces |/a |/louder |/tone, |/and |/air |/produces |/an |/even |/louder |/tone Following |/techniques |/hep |/develop |/proficiency |/in |/the |/technique |/of |/indirect |/percussion |/- |/CORRECT |/ANSWERS |/โโ-place |/the |/middle |/finger |/of |/your |/nondominant |/hand |/on |/the |/body |/part |/you |/are |/going |/to |/percuss -keep |/your |/other |/fingers |/off |/the |/body |/part |/being |/percussed |/because |/they |/will |/damp |/the |/tone |/you |/elicit -use |/the |/pad |/of |/your |/middle |/finger |/of |/the |/other |/hand |/to |/stroke |/the |/middle |/finger |/of |/your |/nondominant |/hand |/that |/is |/placed |/on |/the |/body |/part -withdraw |/your |/finger |/immediately |/to |/avoid |/damping |/the |/tone -deliver |/ 2 |/quick |/taps |/and |/listen |/carefully |/to |/the |/tone -use |/quick, |/sharp |/taps |/by |/quickly |/flexing |/your |/wrist, |/not |/your |/forearm Auscultation |/- |/CORRECT |/ANSWERS |/โโ-assessment |/technique |/that |/requires |/the |/use |/of |/a |/stethoscope |/to |/listen |/for |/heart |/sounds, |/movement |/of |/blood |/through |/the |/cardiovascular |/system, |/movement |/of |/the |/bowel, |/and |/movement |/of |/air |/through |/the |/respiratory |/tract -sounds |/detected |/using |/auscultation |/are |/classified |/according |/to |/the |/intensity |/(loud |/or |/soft), |/pitch |/(high |/or |/low), |/duration |/(length), |/and |/in |/quality |/(musical, |/crackling, |/raspy) |/of |/the |/sound
Guidelines |/to |/practice |/technique |/of |/auscultation |/- |/CORRECT |/ANSWERS |/โโ-eliminate |/distracting |/or |/competing |/noises |/from |/the |/environment |/ -expose |/the |/body |/part |/you |/are |/going |/to |/auscultate -use |/the |/diaphragm |/of |/the |/stethoscope |/to |/listen |/for |/high-pitched |/sounds, |/such |/as |/normal |/heart |/sounds, |/breath |/sounds, |/and |/bowel |/sounds, |/and |/press |/the |/diaphragm |/firmly |/on |/the |/body |/part |/being |/auscultated -use |/the |/bell |/of |/the |/stethoscope |/to |/listen |/for |/low-pitched |/sounds |/such |/as |/abnormal |/heart |/sounds |/and |/bruits Sounds |/(tones) |/elicited |/by |/percussion |/- |/CORRECT |/ANSWERS |/โโ- Resonance |/(heard |/over |/part |/air |/and |/part |/solid)-LOUD |/INTENSITY, |/LOW |/PITCH, |/LONG |/LENGTH, |/HOLLOW |/QUALITY -Hyperresonance |/(heard |/over |/mostly |/air) |/- |/VERY |/LOUD |/INTENSITY, |/LOW |/PITCH, |/LONG |/LENGTH, |/BOOMING |/QUALITY -tympany |/(heard |/over |/air) |/- |/LOUD |/INTENSITY, |/HIGH |/PITCH, |/MODERATE |/LENGTH, |/DRUMLIKE |/QUALITY -dullness |/(heard |/over |/more |/solid |/tissue) |/- |/MEDIUM |/INTENSITY, |/MEDIUM |/PITCH, |/MODERATE |/LENGTH, |/THUD-LIKE |/QUALITY -flatness |/(heard |/over |/very |/dense |/tissue) |/- |/SOFT |/INTENSITY, |/HIGH |/PITCH, |/SHORT |/LENGTH, |/FLAT |/QUALITY
-lower |/leg |/is |/slightly |/flexed |/at |/the |/knee |/while |/the |/upper |/leg |/is |/flexed |/at |/a |/sharper |/angle |/and |/pulled |/foward -assessing |/rectal |/and |/vaginal |/areas Standing |/position |/- |/CORRECT |/ANSWERS |/โโ-stands |/still |/in |/a |/normal, |/comfortable, |/resting |/posture -assess |/posture, |/balance, |/and |/gait -examining |/male |/genitalia Prone |/position |/- |/CORRECT |/ANSWERS |/โโ-lies |/down |/on |/the |/abdomen |/with |/the |/head |/to |/the |/side -used |/primarily |/to |/assess |/the |/hip |/joint -back |/can |/also |/be |/assessed |/with |/the |/client |/in |/this |/position -clients |/with |/cardiac |/and |/respiratory |/problems |/cannot |/tolerate |/this |/position Knee-chest |/position |/- |/CORRECT |/ANSWERS |/โโ-kneels |/on |/the |/exam |/table |/with |/the |/weight |/of |/the |/body |/supported |/by |/the |/chest |/and |/with |/knees -arms |/are |/placed |/above |/the |/head, |/with |/the |/head |/turned |/to |/one |/side -examining |/the |/rectum
Lithotomy |/position |/- |/CORRECT |/ANSWERS |/โโ-lies |/on |/the |/back |/with |/the |/hips |/at |/the |/edge |/of |/the |/examination |/table |/and |/the |/feet |/supported |/by |/stirrups
